HomeMy WebLinkAbout022-1055-70-000
n cn O K v 0
m m COD 'o
. T a c
D 3 m `
- C *•a
Q
,J. z 2 i~ o N r T
1~.7P. O D) U j
N 7 N N
CL~ d O (G
° ° CO
f C
co CD CD W 5 r c C~~ C 1
N O N C = (J
O 'I7 5. Q CD N n A p
C) CD (D a) CL
7 rn CD 0 O C
V
°o o O N
p d CD
z G A
CD O n Q
TJ ~ C
CD
O N ~
- CL
z n r vi
° CO fl
~
Jo Jo o c
s
to 'D ~ T N ~ N`4 s
z O O O m Y
°
' Q N m V 4
v o a N
m in o
m v v N go V
ID = N r N
m rn o
~ d c
N ( - Q
Sl3 ~
z
° z m z
D CD °
c U
m (D V)
O N
~C:- O CD
O p ? ;o n
z O
r~ n O O
o
0o v m N o
m m _ °J
3 A
3
z
CD A
N
M 'O =Z CD C- r !n
N Co X O m S 0 ry
N O°° 3 N O O O.
° 7.' CD 7 C
CD 0 O. G 5-0 cn N `G 4 O "6 N' O T
_ N O CJ
00 0 Cn 7 0 0 0= ~
O cn p~ (D (O_ O O z O.
O O CVO CD ~ ~ ~
D 7 CD N G
a~ rr.
(D r CD 0 -:D cOp O
N a N
O ° A C _
-O O CD N 3 a
rn Q° Ut O N ^s
O J F CD CON O
N Q CJ a
C CD
O - m 7 V O_
j (D Cn ' CD ~
CO
3 s o 3 O r
CD v _ N r
7
O N
CD 7 CD Q C w
N O 7 v ~ < ~ tv
a rn o
~a... C) °a o
m a
(D
N
CD la
4r
p
O (CAL
Wisconsin Depextmrnt of Health sand Sooi+el Snrvir!%s
Plb. -467 3 70 Division of Health
SEPTIC TANK PERMIT APPLICATION -
pet "I'l-s
TYPE or bSa BLACK INn
A. OWNER OF_PROPER
TY-4d~ y 7;13 - ~4r/ ~hhS4Y~ /~~2 N~/y
Name Lk ~a j 7 Address (Street, city, Zip Code
B. LOCATION OF PRO?QTY WFTRE SYS I'tt WILL BE CONSTRUCTED, ALTEREL OR EXTL-tiDED COUN""11 6
Check One; `7
CITY VILLAGE LEGAL DESCRIPTION OZ
TOWN)' A
/zt
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO ~ PER,uIT NLPtBEf:
D. SEPTIC TAla CAPACITY Gallons NEW INSTALLATION REPLACaSNT .-DDIT10N
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE I..ISTALLED: 7
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence Coan..ercial ladustrial other
(Specify)
Number of persons to be Accor.;.^cdated Number of fiedrooeis F. APPLIANCES, ETC: Food :Taste Grinder YES, NO Automatic Clothes Washer YiS_
NO
Dishwasher YES i7v Autc--.t'c Potato Peeler YeS NO
Other (Specify)
FG MASTER PL;;Y9ER MAKING ,ISTALLATIO,N
Nye: Address: L License t :rmb-
1 Signature of Apalioas-it:
Address:
f t t!,°"l ~~~-~t~'✓
I
H• (To a C720 eted by Issui:g Agent)
Date of Application Fee Paid
Permit Issued (dat f oZ /7 Permit N tber v ~G , ,
Agent (Name) For: Town, illage, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forcNard application, the fee of $1.00 for each septic tanx krd the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made pa Is to
the Division of Heaitn.
Do not write in zpace below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED 3 `-76 ACCEPTED BY RETURNED
(Initials) (Date) ~(S Corres.)
FEE RECEIVED VALID. No. S PERMIT NO.
1(res or No _
REVIEWED BY APPROVED DATE
(Initials)
.Yes or No
COMPLETE OTHER SIDE
SEFITIC TANK PERMIT NO. Z -:z~l
R X P O R T O N S O I L P L R C 0 L A T I 0 N ? Y S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SIRCTIN
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P% R C 0 L A T 1 0 N T T S T
Test~~ Dapttt~' Cnaraetar of S2il Hors Water Test Ti DSn slate: level mazes Ut93
Number Inches Thiel ;;33 in Irohos Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted OvemlS t in Minutes Lest Period Last Period Fer'od Ono, Inch
Example
P - 0 36" ?o Soil_ 10"x. Clay 26" 25 Yes or No 30 1/2 1/2 1/2 60 ~
J.
L: LO
- ~ RECORD DATA FROM M L4L% UM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L 2 0 R I N G S- Mint im 36" Bplag Proposed Absorption yz
Boring Total Depth D,3ph to Ground Water Depth to Bedrock
Number Inoh9s Observed Estimated Observed Est-- Character of Soil with Thio)m9ss in Inches
B - 0 72" 72" Black Too Soil 12; Clay 18"; Sand 18"q Gr vol 24"i
D
RE:kIRD DATA FROM MINDIUM OF 3 BORE HOI_ ~
YPE OF OCCUPANCY: -7
RESIDENCE: Nimher of Bedrouas OTHER: (Specify) Number of Persons
D WASTE GRIiZZR: Yea N'l Dis:•=asher: Yes Z~ No Automatic Clothes Washer: Yes No
21-
EFFLUENT DISPOSAL SYSTe'~,~i: KU -/L EXTENSION ADDITION REPLACE4WtT
Tile Size No.Lin.Fest Trench Width Depth Number of Lines
Seepage Beds Lergtht.L.i6-Width Depth,~G Tile Size No. Lines
Seepage Pit: Inside Diameter Liquid Depth
I, the undersigned, hereby esrt'fy that the percolation tests reported in this fora were made by me or e..zder n super-
vision in accord with the procedures and method specified in Chapter H 52.20 (13)0 Wisoonsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knorled6a and belief.
N.4MS 0616 TITLE CMG ,<7
(Type or Print
REGISTRATION NO. _ or MASTER PLLMF.R LIC USE NO.
ADDRESS L~~R /-"/ZL 'S
DATE /7 o SIGNATURE
~Ys6y, Sec • 3~
'fo h 1'50 ~-96a s y3 3 1-71 ' P
lq-7 1 yea - Sl 3
73 QC- -7
--)(b ~.olaShi'17Tki~,r 7 ~h his ~ na.*"Ae-
r-r
5 s ~/sue
-2 -7 ' Z 3 - L
Parcel 022-1055-70-000 07/11/2007 05:08 PM
PAGE 1 OF 1
Alt. Parcel 19.28.18.304D 022 - TOWN OF KINNICKINNIC
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - MOORE, JEFFREY C
JEFFREY C MOORE
1004 QUARRY RD
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description 1004 QUARRY RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.760 Plat: N/A-NOT AVAILABLE
SEC 19 T28N R18W.76A IN SE S Block/Condo Bldg:
241.7'W OF SE COR SE1/4 TH 158' N
208.7' TH E 158' TH S TO POB AL Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
BETWEEN ABOVE DESC PARCEL & RIVER 19-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/24/1999 603692 1428/507 WD
~b~tnSdr~ g 60 V&I-n 6 L VL4 a--,-, ,
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/10/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.760 60,000 216,100 276,100 NO
Totals for 2007:
General Property 0.760 60,000 216,100 276,100
Woodland 0.000 0 0
Totals for 2006:
General Property 0.760 60,000 216,100 276,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 526
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00